Long-Term Maintenance of Cardiorespiratory Fitness Gains After Cardiac Rehabilitation Reduces Mortality Risk in Patients With Multimorbidity.

PURPOSE: The objective of this study was to characterize the impact of multimorbidity and cardiorespiratory fitness (CRF) on mortality in patients completing cardiac rehabilitation (CR). METHODS: This cohort study included data from patients with a history of cardiovascular disease (CVD) completing a 12-wk CR program between January 1996 and March 2016, with follow-up through March 2017. Patients were stratified by the presence of multimorbidity, which was defined as having a diagnosis of ≥2 noncommunicable diseases (NCDs). Cox regression analyses were used to evaluate the effects of multimorbidity and CRF on mortality in patients completing CR. Symptom-limited exercise tests were completed at baseline, immediately following CR (12 wk), with a subgroup completing another test at 1-yr follow-up. Peak metabolic equivalents (METs) were determined from treadmill speed and grade. RESULTS: Of the 8320 patients (61 ± 10 yr, 82% male) included in the analyses, 5713 (69%) patients only had CVD diagnosis, 2232 (27%) had CVD+1 NCD, and 375 (4%) had CVD+≥2 NCDs. Peak METs at baseline (7.8 ± 2.0, 6.9 ± 2.0, 6.1 ± 1.9 METs), change in peak METs immediately following CR (0.98 ± 0.98, 0.83 ± 0.95, 0.76 ± 0.95 METs), and change in peak METs 1 yr after CR (0.98 ± 1.27, 0.75 ± 1.17, 0.36 ± 1.24 METs) were different ( P < .001) among the subgroups. Peak METs at 12 wk and the presence of coexisting conditions were each predictors ( P < .001) of mortality. Improvements in CRF by ≥0.5 METS from baseline to 1-yr follow-up among patients with or without multimorbidity were associated with lower mortality rates. CONCLUSION: Increasing CRF by ≥0.5 METs improves survival regardless of multimorbidity status.

Proof of Concept for a Mindfulness-Informed Intervention for Eating Disorder Symptoms, Self-Efficacy, and Emotion Regulation among Bariatric Surgery Candidates.

Up to 64% of patients seeking bariatric (weight-loss) surgery report eating disorder (ED) symptoms (addictive-like eating, binge eating, emotional eating, grazing) that can interfere with post-surgical weight loss. This prospective proof-of-concept study aimed to evaluate the impact of a pre-surgical mindfulness-informed intervention (MII) on ED symptoms and potential mechanisms-of-action to inform optimization of the intervention. Surgery-seeking adults attended four, 2-hour, MII sessions held weekly. Participants completed validated questionnaires assessing ED symptoms, eating self-efficacy, emotion regulation, and mindful eating pre-MII, post-MII, and at a 12-week follow-up. The MII consisted of mindfulness training, with cognitive, behavioral, and psychoeducational components. Fifty-six patients (M = 47.41 years old, 89.3% female) participated. Improvements in addictive-like eating, binge eating, emotional eating, and grazing were observed from pre- to post-MII. ED symptom treatment gains were either maintained or improved further at 12-week follow-up. Eating self-efficacy and emotion regulation improved from pre-MII to follow-up. Scores on the mindful eating questionnaire deteriorated from pre-MII to follow-up. In mediation analyses, there was a combined indirect effect of emotion regulation, eating self-efficacy, and mindful eating on grazing and binge eating, and an indirect effect of emotion regulation on emotional eating and addictive-like eating. Participation in the MII was associated with improvements in ED symptoms and some mechanisms-of-action, establishing proof-of-concept for the intervention. Future work to establish the MII's efficacy in a randomized controlled trial is warranted.

The impact of patient education on knowledge, attitudes, and cardiac rehabilitation attendance among patients with coronary artery disease.

OBJECTIVE: Patient education (PE) delivered during exercise-based cardiac rehabilitation (CR) aims to promote health behaviour change, including attendance at CR exercise sessions, by imparting knowledge about coronary artery disease (CAD) and improving CR-related attitudes. This study evaluated the impact of PE on aspects of patient motivation (i.e., CAD-related knowledge, attitudes towards CR) and exercise session attendance. METHODS: Adults with CAD referred to a 12-week CR program were recruited. CAD knowledge, perceived necessity/suitability of CR, exercise concerns, and barriers to CR were assessed pre/post-PE, and at 12-week follow-up. CR exercise attendance was obtained by chart review. RESULTS: Among 90 patients (60 ± 10 years; 88% men), CAD knowledge and perceived necessity of CR improved pre- to post-PE; gains persisted at 12-weeks. Stronger pre-CR intentions to attend exercise sessions predicted greater attendance. Greater knowledge gains did not predict improvements in CR attitudes or exercise attendance. CONCLUSION: Whereas PE may be useful for improving knowledge and attitudes regarding CAD self-management, more formative research is needed to determine whether PE can promote CR attendance. PRACTICE IMPLICATIONS: Cardiac PE programs may be more successful in promoting exercise attendance if they target patients' behavioural intentions to attend and attitudes toward CR, rather than focussing exclusively on imparting knowledge.

A qualitative study to identify factors that influence patients' decisions to call Emergency Medical Services for syncope.

BACKGROUND: Protocols that support paramedics to assess, treat and refer low-risk syncope (fainting) may allow for ED transport of only high-risk patients. The development and uptake of such protocols is limited by a dearth of information about factors patients consider when deciding to seek EMS care following syncope. OBJECTIVE: We explored decision-making processes of individuals with syncope regarding whether (or not) to call EMS after fainting as a starting point in the development of prehospital risk-stratification protocols for syncope. METHODS: Twenty-five Canadian adults (aged 18-65 years) with a history of ≥ 1 syncopal episode were recruited. Individual semi-structured interviews were conducted, recorded, and transcribed. Straussian grounded theory methods were used to identify common themes and a core (overarching) category. RESULTS: Four themes were identified: (a) previous experiences with the healthcare system (e.g., feeling dismissed), (b) individual patient factors (e.g., age, medical history), (c) attitudes and beliefs (e.g., burdening the health care system, syncope is "not serious"), and (d) contextual factors (e.g., influence of important others, symptom severity). Perceived judgement, including judgement from EMS and negative self-evaluations, was identified as the core category that influenced patients' decisions to seek care. CONCLUSION: We theorize that, while patients consider many factors in deciding to contact EMS for syncope, previous experiences of feeling judged and unfavorable beliefs about syncope may interfere with patients' receptiveness to traditional EMS protocols for syncope. The findings highlight potential patient needs that program developers may wish to consider in the development of prehospital protocols to improve care and satisfaction among patients with syncope.

RéSUMé: CONTEXTE: Les protocoles qui aident les ambulanciers paramédicaux à évaluer, traiter et orienter les patients à faible risque de syncope (évanouissement) peuvent permettre le transport de patients à haut risque seulement. L'élaboration et l'adoption de tels protocoles sont limitées par un manque d'information sur les facteurs dont les patients tiennent compte lorsqu'ils décident de demander des soins médicaux après une syncope. OBJECTIF: Nous avons exploré les processus décisionnels des personnes en syncope concernant l'appel (ou non) à EMS après un évanouissement comme point de départ dans l'élaboration de protocoles de stratification des risques préhospitaliers en cas de syncope. MéTHODES: Vingt-cinq adultes canadiens (âgés de 18 à 65 ans) ayant des antécédents d'épisode syncopal ≥ 1 ont été recrutés. Des entretiens individuels semi-structurés ont été menés, enregistrés et transcrits. Des méthodes de théorie straussienne ont été utilisées pour identifier les thèmes communs et une catégorie de base (globale). RéSULTATS: Quatre thèmes ont été identifiés: (a) expériences antérieures avec le système de soins de santé (par exemple, Se sentir rejeté), (b) facteurs individuels du patient (par exemple, âge, antécédents médicaux), (c) attitudes et croyances (par exemple, fardeau pour le système de soins de santé, la syncope n'est "pas grave"), et (d) facteurs contextuels (c.par exemple, influence d'autres personnes importantes, gravité des symptômes). Le jugement perçu, y compris le jugement du SME et les auto-évaluations négatives, a été identifié comme la catégorie principale qui a influencé les décisions des patients de se faire soigner. CONCLUSION: Nous théorisons que, bien que les patients tiennent compte de nombreux facteurs lorsqu'ils décident de communiquer avec le AMU pour une syncope, les expériences antérieures de se sentir jugé et les croyances défavorables au sujet de la syncope peuvent nuire à la réceptivité des patients aux protocoles traditionnels de EMS pour la syncope. Les résultats mettent en évidence les besoins potentiels des patients que les concepteurs de programmes pourraient vouloir prendre en compte dans l'élaboration de protocoles préhospitaliers pour améliorer les soins et la satisfaction des patients atteints de syncope.

Promoting adherence to physical activity among individuals with cardiovascular disease using behavioral counseling: A theory and research-based primer for health care professionals.

Physical activity (PA) promotion remains a cornerstone of primary and secondary prevention efforts to reduce morbidity and mortality from cardiovascular disease (CVD). While frontline health care providers (HCPs; e.g., family physicians, cardiologists, registered nurses, nurse practitioners, etc.) are in an optimal position to administer PA-promoting interventions to their patients, many HCPs may feel ill-equipped to address common obstacles to implementing and maintaining complex health behavior change. Behavioral counseling refers to a collection of theory- and empirically-supported strategies and approaches to health behavior promotion that can be learned and applied by HCPs for CVD prevention and treatment. In this selective review, we discuss prominent theories of health behavior change and the empirical intervention literature regarding PA promotion in community and CVD-samples and provide practical recommendations for integrating effective behavioral counseling strategies to clinical practice for frontline HCPs. We argue that behavioral counseling interventions for PA can be effectively executed within the contextual constraints of health settings through subtle shifts in communication strategies and brief counseling approaches. The administration of behavioral counseling for PA by HCPs has enormous potential to reduce CVD incidence and progression at a population level.

Identification of Patients With COPD in a Cardiac Rehabilitation Setting: THE COnCuR STUDY.

PURPOSE: To examine the feasibility of screening for chronic obstructive pulmonary disease (COPD) in an outpatient cardiac rehabilitation (CR) setting and to evaluate the detection rate of COPD using a targeted screening protocol. METHODS: A total of 95 patients (62.5 ± 10.0 yr; men, n = 77), >40-yr old with a history of smoking were included in the study sample. Each participant answered the 5-item Canadian Lung Health Test (CLHT) questionnaire assessing symptoms such as coughing, phlegm, wheezing, shortness of breath, and frequent colds. Endorsing ≥1 item was indicative of potential COPD and warranted pulmonary function testing (PFT) and/or spirometry to diagnose or rule out COPD. RESULTS: The CLHT questionnaire identified 44 patients at risk for COPD, with an average of 1.9 ± 1.2 items endorsed. Of the patients who underwent PFT, 6 new cases of mild COPD were diagnosed, resulting in a true positive rate with CLHT screening of 19% and a false-positive rate of 81%. CONCLUSIONS: Implementing the CLHT to patients referred to CR correctly identified COPD in <20% of cases. Using the CLHT to screen for COPD prior to starting CR may not be optimal, due to disparities between true- and false-positive rates.

The Influence of Weight-Related Self-Esteem and Symptoms of Depression on Shape and Weight Concerns and Weight-Loss 12 Months After Bariatric Surgery.

INTRODUCTION: While body image can improve following bariatric surgery, a portion of patients continue to experience concerns about weight and shape regardless of weight lost. Research is needed to identify risk factors for post-surgical weight and shape concerns given that body dissatisfaction may contribute to poor outcomes. AIMS: To evaluate whether (1) change in weight-related self-esteem and symptoms of depression from pre- to 12-month post-surgery were associated with change in weight and shape concerns independent of weight-loss; (2) improvement in weight and shape concerns, symptoms of depression, and/or weight-related self-esteem predict greater weight-loss 12 months after bariatric surgery; and (3) improvements in weight-related self-esteem, symptoms of depression, weight concerns, or shape concerns predict weight loss. METHODS: Fifty adults approved to receive bariatric surgery self-reported body mass index and completed validated measures of weight-related self-esteem, symptoms of depression, and weight and shape concerns pre- and 12-month post-surgery. RESULTS: Improvements were observed for weight-related self-esteem, concerns over shape and weight, symptoms of depression, and body mass index from pre- to 12-month post-surgery. Improvement in weight-related self-esteem was associated with concomitant improvements in concerns over shape and weight, independent of weight loss. Improvement in symptoms of depression was associated with improvement in concerns over weight, but not shape. Finally, exploratory analyses indicated that improvements in weight-related self-esteem, and concerns over shape and weight, but not symptoms of depression were associated with improvement in weight-loss. CONCLUSIONS: Weight-related self-esteem may represent an overlooked and important target throughout the bariatric surgery process that could enhance surgical outcomes.

Potentially Modifiable Factors Associated with Adherence to Adjuvant Endocrine Therapy among Breast Cancer Survivors: A Systematic Review.

Adjuvant endocrine therapy (AET) reduces risk of breast cancer recurrence. However, suboptimal adherence and persistence to AET remain important clinical issues. Understanding factors associated with adherence may help inform efforts to improve use of AET as prescribed. The present systematic review examined potentially modifiable factors associated with adherence to AET in accordance with PRISMA guidelines (PROSPERO registration ID: CRD42019124200). All studies were included, whether factors were significantly associated with adherence or results were null. This review also accounted for the frequency with which a potentially modifiable factor was examined and whether univariate or multivariate models were used. This review also examined whether methodological or sample characteristics were associated with the likelihood of a factor being associated with AET adherence. A total of 68 articles were included. Potentially modifiable factors were grouped into six categories: side effects, attitudes toward AET, psychological factors, healthcare provider-related factors, sociocultural factors, and general/quality of life factors. Side effects were less likely to be associated with adherence in studies with retrospective or cross-sectional than prospective designs. Self-efficacy (psychological factor) and positive decisional balance (attitude toward AET) were the only potentially modifiable factors examined ≥10 times and associated with adherence or persistence ≥75% of the time in both univariate and multivariate models. Self-efficacy and decisional balance (i.e., weight of pros vs. cons) were the potentially modifiable factors most consistently associated with adherence, and hence may be worth focusing on as targets for interventions to improve AET adherence among breast cancer survivors.

Bridging the intention-behavior gap for cardiac rehabilitation participation: the role of perceived barriers.

Purpose: Patients referred to cardiac rehabilitation after an acute coronary syndrome event commonly report strong intention to attend, but at least one-third do not participate. This study explored whether well-documented cardiac rehabilitation barriers (e.g., comorbidities, logistical/time constraints, and low social support) moderate the association between intention to participate and actual program enrollment and attendance.Method: Following referral but prior to commencing a 12-week outpatient cardiac rehabilitation program, 100 patients with acute coronary syndrome completed measures of intention to attend cardiac rehabilitation, perceived cardiac rehabilitation barriers, and social support. Program enrollment and attendance were determined by chart review.Results: Despite high reported intention to attend (M = 6.08/7.00, SD = 1.80), nearly one-in-five did not enroll. Weaker intention to attend (b = 0.46, SE = 0.16, p = 0.004) and greater cardiac rehabilitation barriers (b= -1.67, SE = 0.70, p = 0.017) corresponded to lower program enrollment. Similarly, weaker intention (b = 2.29, SE = 0.50, p < 0.001) and greater barriers (b =-6.19, SE = 1.55, p < 0.001) predicted poorer attendance. Barriers moderated the association between intention to participate and cardiac rehabilitation enrollment (b=-0.60, SE = 0.29, p = 0.037) and attendance (b = -3.12, SE = 1.02, p = 0.003).Conclusions: Perceived cardiac rehabilitation barriers influence whether patients successfully translate their intention to attend into actual program participation. Enhancing self-efficacy to overcome barriers may represent an important intervention target among prospective cardiac rehabilitation patients.Implications for RehabilitationPatients with acute coronary syndrome report strong intention to attend cardiac rehabilitation upon referral, yet cardiac rehabilitation programs remain underutilized.Assessing and addressing perceived barriers during the transition to cardiac rehabilitation, even when patients present as highly motivated to attend, may be critical to promoting program uptake.Rehabilitation professionals should ask patients about specific barriers to attending cardiac rehabilitation (e.g., financial constraints, transportation problems) and provide individualized solutions (e.g., fee subsidization, home- or web-based programs) to increase participation.

Integrating Science, Practice, and Mentorship in Cardiac Rehabilitation: THE INAUGURAL TOTALCARDIOLOGY® RESEARCH NETWORK RETREAT.

The evidence base supporting cardiac rehabilitation is substantial and overwhelmingly supports its utilization for all qualified patients. However, important lines of inquiry remain and require attention. This commentary provides a model for cardiac rehabilitation centers that provide patient care to meaningfully contribute to our scientific understanding of this lifestyle intervention.

Emotion Self-Regulation Moderates the Association Between Symptoms of ADHD and Weight Loss After Bariatric Surgery.

BACKGROUND: This study aimed to examine the combined effect of pre-surgical emotion self-regulation (ESR) and symptoms of attention deficit hyperactivity disorder (sADHD, i.e., inattention, impulsivity, and hyperactivity) on weight loss 12 months following bariatric surgery independent of psychological distress and eating pathology. METHODS: Adults with obesity were recruited from a bariatric surgery specialty clinic in Canada. Patients completed measures of psychological distress (i.e., Beck Depression Inventory II and Beck Anxiety Inventory), eating pathology (i.e., Eating Disorder Examination Questionnaire), ESR (i.e., "Managing Own Emotions" subscale of the Schutte Emotional Intelligence Test), and sADHD (i.e., Adult ADHD Self-Report Scale) prior to surgery. Measures of height and weight were obtained and used to calculate percent excess weight loss (%EWL) of body mass index (BMI) pre- and 12 months post-surgery. RESULTS: Thirty-seven patients were recruited. The final sample consisted of 30 patients (80% female; mean age = 48 years; mean BMI = 49.32). Patients experienced significant weight loss and reported significant improvement in anxiety, depressed mood, and eating pathology from pre- to 12 months post-surgery. A significant sADHD by ESR interaction on %EWL (F(1, 21) = 6.43, p = .019) was observed and accounted for 13% of unique variance after adjusting for relevant covariates. Probing the interaction with the Johnson-Neyman technique indicated that there was a significant inverse association between sADHD and %EWL among individuals who scored ≤ 0.15 SD below the mean on ESR. CONCLUSIONS: ESR moderated the association between sADHD and %EWL, suggesting that sADHD may attenuate weight loss following bariatric surgery among individuals deficient in ESR. This finding has implications for bariatric surgery pre-surgical psychological assessment.